Medical device engineers are great at designing innovative, life-saving gizmos. Sometimes, however, it’s hard to anticipate everything that might go wrong with a device, even something as innocuous as a tubing connector.
Years ago, tubing for gases and IV fluids shared the same plastic connector, which was designed for quick, secure installation. The connectors worked exactly as intended. But, when patients or their loved ones disconnected the lines, they would occasionally reconnect them incorrectly. Thus, an air line for an automatic blood-pressure monitor would inadvertently get connected to an IV line—with disastrous results. Today, that connector can only be used with IV lines, and different connectors have been designed for gas lines.